Every finding on record at Life Care Center of Lewiston

Based on interview, record review, and review of facility procedure, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected medications received for three residents (Resident (R)6, R4, and R22) out of a total sample of 19 residents. These failures created potential for an incomplete or ineffective plan of care related to medication effectiveness and side effects.Findings include:1. Review of R6's admission Record located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) and major depressive disorder.Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/25 and located under the MDS tab of the EMR revealed he was coded as receiving anticoagulant medication (slows or inhibits the clotting of blood), receiving antidepressant medication, and as not receiving antiplatelet medication (prevents blood platelets from clumping together).Review of R6's Order Summary Report for active orders as of 05/21/25 and located under the Orders tab of the EMR revealed orders for clopidogrel bisulfate (an antiplatelet medication) 75 milligrams (mg) daily for blood clot prevention and Lexapro (an antidepressant) 5mg daily for depressive disorder. The report indicated R6 had no orders for anticoagulant medication.Review of the Medication Administration Record (MAR) dated 05/01/25 to 05/31/25 and located under the Orders tab of the EMR revealed R6 received clopidogrel daily and received no anticoagulant medication. R6's Lexapro was coded as 10 each day from 05/15/25 to 05/21/25 which referred the reviewer to see progress notes.Review of R6's Orders-Administration Notes dated 05/15/25 to 05/21/25 located under the Progress Notes tab of the EMR revealed his Lexapro was not available.During an interview on 07/31/25 at 10:05 AM, MDS Coordinator (MDSC2) reported she was unsure whether clopidogrel bisulfate was coded as an anticoagulant or antiplatelet on the MDS. She checked on the coding guidance and stated that clopidogrel bisulfate was an antiplatelet medication. MDSC2 stated R6's MDS dated [DATE] was incorrectly coded because the clopidogrel was documented as an anticoagulant and not as an antiplatelet. In addition, MDSC2 stated an MDS reflected only medications received during the seven-day look-back period. She reviewed R6's MAR from 05/15/25 to 05/21/25 and reported she needed to correct the MDS since R6 did not receive his antidepressant medication.2. Review of the admission Record located in the EMR under the Profile tab revealed R4 was admitted to the facility on [DATE] and had diagnoses including history of transient ischemic attack (TIA) and cerebral infarction (stroke).Review of the quarterly MDS with an ARD of 05/15/25 in the EMR under the MDS tab revealed R4 was coded as receiving anticoagulant medication and as not receiving antiplatelet medication.Review of R4's Order Summary Report for active orders as of 05/15/25 and located under the Orders tab of the EMR revealed orders for clopidogrel bisulfate (an antiplatelet medication) 75mg daily for anticoagulant. R4 had no orders for any anticoagulant medication.During an interview on 07/31/25 at 10:05 AM, MDSC2 reported she had coded R6's clopidogrel as an anticoagulant since the order stated, for anticoagulant. MDSC2 then stated since clopidogrel was supposed to be coded as an antiplatelet, she needed to modify R6's MDS to show that she received an antiplatelet medication and not an anticoagulant medication.3. Review of the admission Record located in the EMR under the Profile tab revealed R22 was admitted to the facility on [DATE] and had diagnoses including gastroparesis.Review of R22's quarterly MDS with an ARD of 07/07/25 in the EMR under the MDS tab revealed he was coded as not receiving any antibiotic medication.Review of R22's Order Summary Report for active orders as of 07/07/25 and located under the Orders tab of the EMR revealed an order dated 10/01/24 for erythromycin (an antibiotic) 250mg capsule before meals for gastroparesis prevention.Review of R22's MAR dated 07/01/25 to 07/31/25 and located under the Orders tab of the EMR revealed he received the antibiotic medication daily.During an interview on 07/31/25 at 10:05 AM, MDSC2 reported she missed that R22 received antibiotic medication and that she planned to correct the MDS right away to reflect the medication.During an interview on 08/01/25 at 11:25 AM, the Director of Nursing (DON) stated he expected medications to be coded correctly on the MDS.Review of the facility's Certification of Accuracy of the MDS policy, revised 04/22/25, revealed, The assessment must accurately reflect the resident's status. The assessment must represent an accurate picture of the resident's status during the observation period of the MDS. The observation period [also known as the look-back period] is the time frame over which the resident's condition or status is captured by the MDS assessment .

Based on record review, interview, and policy review, the facility failed to ensure one of three residents (Resident (R) 11) reviewed for falls was assessed for injury by a licensed nurse prior to being moved by the Certified Nurse Aides (CNAs). This failure had the potential to contribute to exacerbated injury upon movement prior to assessment.Findings include:Review of R11's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, adult failure to thrive, osteoarthritis, osteoporosis, and anxiety. Review of R11's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/01/25 and located under the MDS tab of the EMR, revealed she was unable to complete the Brief Interview for Mental Status (BIMS) and she was assessed with memory problems and severely impaired cognition. R11 was dependent on assistance from staff with bed mobility, transfers, and locomotion.Review of R11's Event Note, dated 07/05/25 and located under the Progress Notes tab of the EMR, revealed, RN [Registered Nurse] summoned to residents [sic] room. Resident noted within bed at this time. CNA explained that while providing cares when rolling resident towards her, resident rolled OOB [out of bed] onto CNA. CNA was able to maneuver 'out from underneath' resident and to locate another CNA to assist with returning resident to bed with mechanical lift. Review of R11's Incident Report, dated 07/05/25 and provided on paper, revealed she had rolled out of bed while a CNA was providing care, and another CNA was summoned and assisted with putting the resident back to bed. The RN was then summoned to assess R11 and found R11 already in bed. During an interview on 07/31/25 at 10:41 AM, RN13 stated when she was summoned to R11's room, the resident was already in bed. RN13 conducted an assessment and noted abrasions to R11's forehead and knee but no other injuries were noted. RN13 stated the CNAs should have summoned her to conduct an assessment prior to moving the resident off the floor in case of serious injury. RN13 reported CNA6 and CNA7 were involved in the incident.During an interview on 07/31/25 at 12:05 PM, CNA7 stated CNA6 had called her into R11's room after the resident had fallen. She stated upon entering, she found R11 on the floor and assisted CNA6 to move the resident from the floor to the bed using the mechanical lift. CNA7 stated after R11 was put back into bed, RN13 was alerted of the fall and came to assess the resident. CNA7 did not see any assessment of R11 occur prior to moving her back to bed but noted the resident did not have any signs or symptoms of injury. CNA7 stated she was not aware the resident should be assessed prior to being moved off the floor prior to this incident, but was given verbal education by the nurse that R11 should have remained on the floor until she was assessed by the RN. During an interview on 07/31/25 at 12:40 PM, CNA6 stated while she was providing incontinence care to R11, the resident rolled off the bed and on top of the CNA. After R11 fell, CNA6 got out from under R11, turned on the call light, and found CNA7 to help. CNA6 stated she and CNA7 transferred R11 back to bed using a mechanical lift, then alerted RN13 of the fall. CNA6 stated she had been educated several times by the facility on the need to leave a resident on the floor until an assessment was completed by the RN. She stated in this case, no assessment had been conducted prior to transferring R11 back to bed; however, she noticed the resident was not crying, grimacing, or acting like she was in pain and had no visible injuries. CNA6 stated she was stressed by the situation and worried about getting the resident cleaned up and she did not follow her usual protocol. During an interview on 07/31/25 at 12:50 PM, the Administrator stated CNA6 and CNA7 had received verbal counseling by RN13 on not moving a resident before an assessment by the licensed nurse, but there was no documentation of the education. Review of CNA7's training records, provided on paper, revealed she received training on the Incident & [and] Reportable Event Management policy, which directed staff not to move a resident after a fall before an assessment by a licensed nurse, on 05/21/25. Evidence of CNA6's training on the Incident & Reportable Event Management policy was not provided prior to survey exit.During an interview on 08/01/25 at 12:06 PM, the Director of Nursing (DON) stated professional standards dictate a resident be assessed for injury by a licensed nurse prior to being moved after a fall, even if there were no overt signs of injury.Review of the policy titled, Incident & Reportable Event Management, dated 09/25/24, revealed, The licensed nurse should evaluate the resident and render first aide if needed. The nurse evaluation should be completed prior to moving a resident who has fallen, to determine presence of injury.

Based on record review, staff interview, and policy review, the facility failed to ensure there was no delay in treatment of a newly identified pressure ulcer for one of two residents (Resident (R) 10) reviewed for pressure ulcers. This failure had the potential to slow healing or lead to wound infection.Findings include:Review of R10's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with diagnoses including alcoholic polyneuropathy, malnutrition, muscle wasting, quadriplegia, multiple contractures, two stage III pressure ulcers, and one stage IV pressure ulcer.Review of R10's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/25 and located under the MDS tab of the EMR, revealed he scored nine out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. He had one stage II pressure ulcer that was facility-acquired and two pressure ulcers that were present on admission.Review of R10's Care Plan, dated 06/06/25, documented, Has break in skin integrity, pressure injury to right hip and right buttock, Scrotum and MASD [moisture-associated skin damage] to groin. The approaches included, Treatment as ordered. Notify MD [physician] if change in tx [treatment] is indicated. Review of R10's Wound Healing and Ostomy Clinic note, dated 07/21/25 and provided on paper, revealed, Wound Care Physician (WCP), dated 07/21/25 and provided on paper, revealed a new right inferior hip wound measuring 1 centimeter (cm) long, 1.5 cm wide, and 0.05 cm deep . There is a wound distal to the right trochanter/posterior thigh that is full thickness that tracks so will continue with current measures here also. The note contained orders for treatment of the right trochanter wound; however, there was no order addressing the inferior right hip wound.Review of R10's Wound Observation Tool, dated 07/21/25 and located under the Assessments tab of the EMR, revealed R10 acquired a new pressure ulcer to the right inferior hip at stage III on 07/21/25. The wound was 1 cm long, 1.5 cm wide, and 0.05 cm deep with moderate red drainage. The assessment documented, Initial Assessment - No wound history to compare. However, the assessment also documented, Resident is assessed weekly by RCM [Resident Care Manager] and seen monthly by [WCP] this date. Measurements show this week that tunneling is deeper but the outside diameter of the wound is unchanged . Treatment to remain the same: Irrigate with Vashe, apply skin prep to peri wound, lightly fill/pack with Iodoform, and cover gauze and secure transparent dressing. Review of R10's July 2025 Treatment Administration Record (TAR), located under the Orders tab of the EMR, revealed from 07/21/25 through 07/28/25, there were no treatment orders addressing the right inferior hip wound. Review of R10's 07/25/25 Skin/Wound Note, dated 07/25/25 and located under the Progress Notes tab of the EMR, revealed, [WCP] noted a new wound to R [right] hip but it is unclear what the wound is or the specifics of this wound. This RCM will contact [WCP] on Monday to follow up as she is out of the office today. Did not open a wound obs [observation] for this wound as it is unclear how to proceed. Review of R10's EMR under the Orders tab revealed the physician's order, dated 07/29/25, R inferior hip wound: Cleanse with Vashe cleanser aggressively, pat dry, apply skin prep to peri wound, apply silver med to wound bed, cover with gauze and secure with transparent film to be completed every Monday and Thursday. During an interview on 08/01/25 at 9:33 AM, RCM2 stated the WCP noted a new wound inferior to the older wound on R10's right hip on 07/21/25. She stated R10 went out to see the WCP on 07/21/25 and came back with paperwork that documented a new wound and its measurements; however, no new orders were noted. RCM2 stated she did not get a hold of the WCP until 07/29/25 to clarify the treatment orders for the new wound. RCM2 stated she was unable to find any documentation indicating wound treatment orders were obtained and wound treatments were implemented between 07/21/25 and 07/29/25. RCM2 stated typically, a resident would come back with paperwork with new orders for wound care and the orders would be entered into the EMR and carried out; however, the paperwork for R10 from the WCP did not have clear orders for treatment and needed to be clarified before they could be entered in the system and carried out. She stated it took a long time to get the order clarified, as the WCP was hard to get a hold of. RCM2 stated she had documented the current order for the superior wound on the 07/21/25 Wound Observation Tool because she did not have any orders to implement for the inferior wound.A call was placed to the WCP on 08/01/25 at 11:24 AM; however, no contact was made.Review of the policy titled, Skin Integrity & [and] Pressure Ulcer/Injury Prevention, dated 08/25/21, revealed, When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident.

Based on record review, interview, and manufacturer's instructions for use of the resident bed, the facility failed to ensure the brakes on the bed were locked for one of three residents (Resident (R) 11) reviewed for falls. This failure caused a fall with minor injury for R11 and had the potential to cause injury from falls.Findings include: Review of R11's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, adult failure to thrive, osteoarthritis, osteoporosis, and anxiety.Review of R11's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/01/25 and located under the MDS tab of the EMR, revealed she was unable to complete the Brief Interview for Mental Status (BIMS) and she was assessed with memory problems and severely impaired cognition. R11 was dependent on assistance from staff with bed mobility, transfers, and locomotion. Review of R11's EMR under the Profile tab revealed, Special Instructions: Mechanical lift for transfers. High fall risk.Review of R11's Care Plan, dated 07/22/25 and located under the Care Plan tab of the EMR, revealed, [R11] is at risk for falls r/t [related to] impaired strength, standing tolerance, balance, activity tolerance. Dementia with Impaired safety awareness, use of antidepressant medication. The approaches included, Keep her bed in appropriate position with safety mat at bedside and When laying resident in bed, make sure resident body is in the center of the bed.Review of R11's Event Note, dated 07/05/25 and located under the Progress Notes tab of the EMR, revealed, CNA explained that while providing cares when rolling resident towards her, resident rolled OOB [out of bed] onto CNA.Review of R11's Incident Report, dated 07/05/25 and provided on paper, revealed, CNA stated that the brake on one or more of the wheels was not locked. This then caused the bed to shift when rolling the resident to the side of the bed.During an interview on 07/31/25 at 12:40 PM, CNA6 stated she had been providing incontinence care for R11. The bed was unlocked, and R11 rolled too far towards the edge of the bed, the bed rolled away, and R11 fell on top of CNA6. CNA6 stated she had unlocked the bed to move the mechanical lift into position, as there was not a lot of room on the side of the bed, and had forgotten to lock it again. During an interview on 07/31/25 at 12:50 PM, the Administrator stated CNA6 had received verbal counseling on locking the bed before providing care; however, there was no documentation of the education.Review of the Mandatory CNA and NA [Nurse Aide] Clinical Meeting record, dated 07/16/25, revealed, Make sure the bed wheels are locked and that the bed is in the lowest position, parallel to the floor. However, CNA6 had not attended this training. Review of CNA6's training records, provided on paper, revealed she received training on locking the bed prior to providing care on 03/27/25.During an interview on 08/01/25 at 12:06 PM, the Director of Nursing (DON) stated the staff were expected to double-check to ensure the bed brakes were locked before providing care, and this was something taught in CNA curriculum and at the facility.Review of the undated Joerns EasyCare Bed Platform User-Service Manual revealed, Warning: Possible Injury or Death. Floor locks increase bed stability and resident safety. Make sure the bed is in a locked position with respect to the floor by ensuring the casters are off the floor or if equipped, the UltraLock is in the locked position before attempting any resident transfers. Failure to do so could result in injury or death . For best practices, the UltraLock feature should be locked at all times, except when the bed is being moved.

Based on interview, record review, and review of facility procedure, the facility failed to ensure a medication was available to administer as ordered for one resident (Resident (R)6) out of a total sample of 19 residents. This failure created potential for the resident to have side effects.Findings include:Review of R6's admission Record located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including major depressive disorder.Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/25 and located under the MDS tab of the EMR revealed he scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment. R6 reported feeling down and having little interest in doing things for several days out of the previous two weeks on the PHQ-2 to 9 interview.Review of R6's Order Recap Summary for orders 03/06/25 to 07/31/25 and located under the Orders tab of the EMR revealed orders for Lexapro (an antidepressant) 5mg daily for depressive disorder from 03/20/25 to 05/27/25.Review of the Medication Administration Records (MAR) dated 04/01/25 to 04/30/25 and 05/01/25 to 05/31/25 and located under the Orders tab of the EMR revealed R6's Lexapro was coded as 10 each day but one from 04/28/25 to 05/27/25 which referred the reviewer to see progress notes.Review of R6's Orders-Administration Notes dated 04/28/25 to 05/27/25 located under the Progress Notes tab of the EMR revealed his Lexapro was not available.Further review of the Progress Notes tab of the EMR from 04/28/25 to 05/27/25 revealed no documentation of why R6's Lexapro was unavailable, communication with the pharmacy, or communication with the physician or nurse practitioner. A Behavior Note dated 05/15/25 documented, Resident reviewed in [behavior meeting] with [social services, resident care managers] and pharmacist. Resident has order for Lexapro 5 mg [daily] for depression, however recent has not taken the medication for over a week. The resident reports that he is feeling well and does not have any concerns, resident's behavior monitor shows no signs or symptoms of depression. Resident placed on alert charting to monitor further. Resident will continue to be monitored in [behavior meeting] going forward next month.Review of R6's Documents tab of the EMR revealed one, undated, communication to the provider stating, Resident has not been taking Lexapro 5mg for 1+ weeks and feels stable without medications. Can we [discontinue] Lexapro order with a response dated 05/27/25 to discontinue the medication. Review of R6's Care Plan tab of the EMR revealed an intervention revised on 07/29/25: Resident has a [diagnosis] of depression but prefers not to take medication at this time. He feels his mental health is well managed without pharmaceutical intervention.During an interview on 07/29/25 at 11:37 AM, R6 denied any concerns with his mood.During an interview on 07/31/25 at 8:08 AM, Registered Nurse (RN) 12 stated medications were re-ordered through the EMR. The pharmacy delivered daily. If a medication was not available, there was a pyxis (emergency supply of medications) and a local pharmacy delivery was able to be arranged for important medications. Sometimes medications were on back-order and not available so RN12 called the doctor to see if another medication was able to be substituted. During an interview on 07/31/25 at 11:50 AM, Licensed Practical Nurse (LPN) 9 recalled R6's Lexapro was unavailable. LPN9 believed it was something to do with insurance. When the doctor was notified R6 was not taking the medication, it was discontinued. During an interview on 08/01/25 at 9:59 AM, the Medical Director stated he ordered Lexapro when R6 clinically seemed depressed. R6 was tearful and did not want to participate in his care. The Medical Director stated he was made aware that R6 was not receiving the Lexapro, but he was unable to recall when he was notified and how long R6 went without the Lexapro before the notification. The Medical Director expected both a notification from the pharmacy as well as an SBAR (situation, background, assessment, recommendation) notification from nursing if medication was not available. Both were expected to be documented in the EMR, but the Medical Director saw no evidence in R6's EMR. During an interview on 08/01/25 at 10:44 AM, Resident Care Manager (RCM) 1 was made aware during a behavior meeting on 05/15/25 that R6 was not receiving his Lexapro. There was an insurance issue, and pharmacy did not contact the facility about it. Nurses were led to believe by the pharmacy that the medication was coming. RCM1 notified R6's physician/nurse practitioner that he had not received his Lexapro, and it was discontinued. The facility's protocol when medications were not available was for nursing to order it online. If it did not arrive, nurses called the pharmacy or asked the RCM1 to call the pharmacy. If a medication was available in the pyxis, it was retrieved from it. If it was not available, the physician was to be notified within two to three days. During an interview on 08/01/2025 at 11:15 AM, LPN10 stated R6's Lexapro was not sent by pharmacy due to a billing issue. LPN10 said if a medication was not available, nursing documented it and contacted the pharmacy. The Medical Director and nurse practitioner were in the facility during the week and were expected to be notified. If they were notified of R6's missed Lexapro doses, the notification should be documented. During an interview on 08/01/2025 at 11:30 AM, the Director of Nursing (DON) reported his expectation was for staff to notify the provider within 24 hours of a medication being unavailable.Review of the facility's Medication Shortages/Unavailable Medications policy, revised 08/01/24, revealed If the medication shortage is discovered at the time of medication administration, Facility staff should immediately notify the Pharmacy. If the next available delivery causes delay or a missed dose in the resident's medication schedule, Facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for a STAT delivery, if medically necessary. If an emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain new orders or directions for alternate administration. If the medication is unavailable from Pharmacy or a third-party Pharmacy, and cannot be supplied from the manufacturer, Facility should obtain alternate Physician/Prescriber orders, as necessary. When a missed dose is unavoidable, Facility nurse should document the missed dose, and the explanation for such missed dose, on the MAR or TAR [treatment administration record] and in the nurse's notes per Facility policy. Such documentation should include the following information: a description of the circumstances of the medication shortage, a description of Pharmacy's response upon notification, and all other action(s) taken.

Based on observations, interviews, record review, and policy review, the facility failed to ensure staff donned (put on) the appropriate personal protective equipment (PPE) required for contact isolation precautions for one of three residents reviewed for transmission-based precautions (Resident (R) 16) as well as failed to ensure one out of one resident (R53) catheter bag was not resting on the floor. This failure had the potential to lead to spread of infection throughout the facility.Findings include:1. Review of R16's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE].Review of R16's Order Note, dated 07/29/25 and located under the Progress Notes tab of the EMR revealed, New order received for po [oral] Valtrex [an antiviral medication] for 14 days and for Prednisolone [an anti-inflammatory medication] to right eye tid [three times a day] until directed to stop. Resident reports that she has shinges [sic] in eyeReview of R16's Skilled Note, dated 07/30/25 and located under the Progress Notes tab of the EMR, revealed, Resident is now Contact Isolation precautions r/t having shingles in her right eye. Resident is in a single room with no roommate. All services are being provided within her room.Review of R16's EMR under the Profile tab revealed, Special Instructions: Contact precautions r/t [related to] shingles.During an observation on 07/30/25 at 8:44 AM, R16's room door had a sign announcing, Contact Isolation and directing all staff to perform hand hygiene and don a gown and gloves prior to room entry. The MDS Coordinator (MDSC) entered R16's room carrying a bottle of milk. She did not perform hand hygiene or don a gown or gloves before entering. In an interview on 07/30/25 at 8:47 AM, the MDSC confirmed she did not wear a gown or gloves and stated the floor nurse, Registered Nurse (RN) 12, had told her that the gown and gloves were not required since she was just dropping something off in the room. In an interview on 07/30/25 at 8:59 AM, RN12 stated R16 was on contact precautions due to a case of shingles in her eye. She stated upon entering her room, everyone should don a gown and gloves. In an interview on 07/30/25 at 9:22 AM, the Director of Nursing (DON) stated the MDSC should have donned gown and gloves before entering R16's room, and he had provided re-education to the MDSC regarding proper PPE use for contact precautions. The DON stated he also would be providing re-education to all staff. During an observation on 07/31/25 at 8:12 AM, Certified Nurse Aide (CNA) 5 entered R16's room with a meal tray in her hands. She did not perform hand hygiene or don a gown and gloves prior to entering. CNA 5 touched R16's overbed table and items in room. In an interview on 07/31/25 at 8:12 AM, CNA 5 stated R16 was on contact precautions for shingles in her eye, and staff were to wear a gown and gloves only for high-contact care, such as toileting or personal hygiene.During an observation on 07/31/25 at 8:44 AM, Activity Assistant (AA) entered R16's room with a stack of daily newsletters. The AA did not sanitize her hands or don a gown and gloves prior to entering the room. While in the room, the AA kneeled on floor to speak with R16.In an interview on 07/31/25 at 8:44 AM, the AA confirmed she had not donned PPE and stated she had not yet been given any information on the need for contact precautions in R16's room. She stated for contact precautions, staff were required to wear a gown and gloves if coming in contact with the resident. The AA was unsure if contact with the floor while kneeling was an activity that required PPE use.In an interview on 08/01/25 at 11:35 AM, the DON stated every time a staff member entered a room where Contact Precautions were in place, they should don the appropriate PPE, even if it was just to drop something off or talk and there was no direct contact with the resident. Review of the facility's policy titled, Transmission-based Precautions and Isolation Procedures, dated 07/02/25, revealed, Contact precautions are intended to prevent transmission of pathogens that are spread by direct (e.g., person-to-person) or indirect contact with the resident or environment, and require the use of appropriate PPE, including a gown and gloves before or upon entering (i.e., before making contact with the resident or environment, and require the use of appropriate PPE, including a gown and gloves before entering (i.e. before making contact with the resident or resident's environment) the room or cubicle. Prior to leaving the resident's room or cubicle, the PPE is removed, and hand hygiene is performed.2. Review of R53's admission Record located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, and retention of urine.Review of R53's Order Summary Report located under the Orders tab of the EMR revealed an order for catheter care every shift. Keep catheter bag placed below the level of the bladder, dated 04/08/25.Review of R53's Care Plan tab revealed he had a chronic foley catheter in place, revised 04/24/25. Interventions included to check for kinks and dependent loops in tubing every shift, observe for and report any symptoms of an infection to the doctor, and use enhanced barrier precautions.Review of R53's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/15/25 and located under the MDS tab of the EMR revealed he scored nine out of 15 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment. R53 had an indwelling catheter.During an observation on 07/30/25 at 8:20 AM, R53 was observed sitting in bed eating breakfast with his urinary drainage bag hanging, uncovered, from his bed frame, urine visible in the bag and the bottom quarter of the bag resting on the floor. During a concurrent interview and observation on 07/30/25 at 8:43 AM, R53 stated he seldom got out of bed, per his choice. R53 reported not caring if his urinary drainage bag was not covered. R53's breakfast tray was no longer in his room. The drainage bag continued to touch the floor.During an observation on 07/30/25 at 9:45 AM, the urinary drainage bag continued to touch the floor. During an observation on 07/31/25 at 5:50 AM, R53 was asleep in bed. His urinary drainage bag was covered by a blue dignity bag. The bottom of the urinary drainage bag rested on the floor.During an observation on 07/31/25 at 8:15 AM, Certified Nursing Assistant (CNA) 4 delivered R53's breakfast tray to his room. The bottom of the urinary drainage bag continued to rest on the floor.During an observation on 07/31/2025 at 8:25 AM, CNA4 and another staff person went into R53's room and told him they were going to boost him up in bed. When they left the room at 8:31 AM, the bottom of the urinary drainage bag continued to rest on the floor. During a concurrent observation and interview at 8:35 AM, Licensed Practical Nurse (LPN) 11 stated the drainage bag should not touch the floor due to infection control reasons and that she would fix it. During an interview on 07/31/2025 at 1:30 PM, CNA4 reported urinary drainage bags were to be placed below bladder level but off the floor. She had not noticed R53's drainage bag touching the floor when she assisted him. During an interview on 08/01/25 at 11:25 AM, the Director of Nursing (DON) said he expected urinary drainage bags to be placed below the bladder and not touching the floor. The facility tried to place the bags towards the bottom of the bed and lowered the bed down so that the bag stayed four to five inches above the floor.Review of the facility's General Urinary Catheter Maintenance Guidance policy, revised 06/06/19, revealed: Do not rest the bag on the floor.

Based on observation, record review, and staff interview, it was determined the facility's Quality Assessment and Performance Improvement (QAPI) committee failed to implement actions and resolve systemic problems which were identified for tracking and monitoring of controlled substances (narcotics). This failure placed residents at risk for pain to experience increased and/or uncontrolled pain levels should they not receive their narcotic medication due to misappropriation. Findings include: A missing narcotics investigation document, dated 3/1/22, documented the following: - LPN #1 reported to the ED concerns about RN #3 signing out controlled medications (narcotics) before and after her shift. - RN #3 often signed out medications for Resident #33 before the shift count verification was completed, prior to the start of her shift. RN #3 signed out medications that were not documented as given on Resident #33's MAR. - RN #3 stated she saved all her notes and enters them at the end of the shift. RN #3 stated she was not aware the medication was missing and confirmed she did not count the narcotics with the night shift nurse the morning of 3/1/22. She stated LPN #1 was busy trying to finish her shift. - LPN #1 stated she could not remember if she and RN #3 formally counted on the morning of 3/1/22, because she was busy assisting a CNA with a resident. LPN #1 was not aware of the missing medications. LPN #1 told the ED this was not her normal practice. - RN #3 and LPN #1 signed the narcotic book without completing the shift count reconciliation. - The ED and DON completed an audit of all narcotics on 3/1/22 at 9:45 AM and Resident #33 had narcotic medications missing from bubble pack #16 (a method to package individual doses of medication within small, clear, or light-resistant amber-colored plastic bubbles). All other narcotics were accounted for. - Medications were missing between 2/28/22 and 3/1/22. The last documented entry on bubble pack #16 was on 2/28/22 at 6:55 PM and was administered by RN #4. Corrective actions in the investigation included: - The facility self-reported the missing narcotics to the State of Idaho's Long-Term Care Reporting portal on 3/1/22 as a Misallocation of Resident Property by Facility Staff. - The pharmacy was informed of the missing narcotics on 3/1/22. - The Social Services Director completed interviews on 3/1/22 with five residents who received scheduled and/or as needed pain medications and found no adverse findings. Resident #33 was included in the interviews. - The local police department was notified of the missing medications on 3/2/22. - The DON and ED were to complete daily audits of the narcotics. A timeframe was not specified which stated how long the audits were to be conducted. On 8/18/22 at 9:00 AM, during observation of the facility's medication storage, the Controlled Substance Record Book was reviewed for facility rooms #101-#106. The shift count verification page included three shift counts to be completed by LNs; the day shift LN with the evening shift LN, the evening shift LN with the night shift LN, and the night shift LN with the day shift LN. There were a total of six signatures required in a 24-hour period. The exception was if an LN worked a double shift. The verfication page had days during June, July, and August 2022 where the LN did not complete the shift count verification for narcotics. There were days with one missing signature and days with multiple missing signatures. On 8/18/22 beginning at 9:15 AM, the Controlled Substance Record Books on the medication carts were reviewed for June, July, and August, 2022 with the DON present: - The book for rooms #101-#106 had nine days with missing shift count verifications in June, 17 days with missing shift count verifications in July, and six days with missing shift count verifications in August. - The book for rooms #108-#124 had five days with missing shift count verifications in June, seven days with missing shift count verifications in July, and two days with missing shift count verifications in August. - The medication cart for rooms #301-#308 and #324-#325 did not have a Controlled Substance Book. During the observation LPN #4 confirmed the medication cart did not have the correct shift count verification form and they made up their own using an index form for documenting individual medications. On this form there were five days with missing shift count verifications in June, 15 days with missing shift count verifications in July, and two days with missing shift count verifications to in August. LPN #4 stated she had the keys to the cart and counted and signed for the narcotic keys in the morning but pre-signed the 2:00 PM change of shift verification which had not yet occurred. At the time of the interview, this would have been more than 4 hours prior to 2:00 PM. On 8/18/22 at 9:24 AM, the IP, who was the DON during the time of the missing narcotics investigation, stated, I probably did not do any audits after 3/1/22. The IP did not provide audits completed after 3/1/22, per the corrective actoin identified in the investigation document. On 8/18/22 at 9:36 AM, the ED stated she was not aware of the continued non-compliance with the shift count verification or that the audits were not completed. On 8/18/22 at 2:29 PM, the ED confirmed the facility failed to implement a process improvement plan to correct the systemic noncompliance for managing controlled substances.

Based on record review, policy review, and resident representative, and staff interview, it was determined the facility failed to ensure residents were provided with bathing consistent with their needs. This was true for 1 of 27 residents (Resident #13) reviewed for activities of daily living. This failure created the potential for residents to experience embarrassment, isolation, decreased sense of self-worth, and skin impairment due to a lack of personal hygiene. Findings include: The facility's Activities of Daily Living policy, dated 7/17/21, stated its purpose was To ensure facilities identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. This policy was not followed. Resident #13 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS assessment, dated 5/19/22, documented Resident #13 was severely cognitively impaired and required extensive assistance of one person for bathing. Resident #13's care plan documented staff were to provide a sponge bath when a full bath or shower could not be tolerated, and for showering he was totally dependent on one staff member to provide showers two times a week and as necessary. The facility's shower schedule for June and July 2022, documented he did not receive showers two times a week as follows: - Resident #13 received a shower on June 8 - Resident #13's next shower was on June 15, 7 days later - Resident #13's next shower was on June 23, 8 days later - Resident #13 received a shower on July 13, 16 days after his last shower On 8/16/22 at 4:00 PM, Resident #13's representative stated she noticed earlier this year he developed body odor which never occurred before. Resident #13's representative stated she purchased body spray and shampoo for him. Resident #13's representative stated the body odor was no longer a problem, but she remained concerned about Resident #13 being kept clean. On 8/18/22 at 8:30 AM, the ED confirmed the shower schedule she provided for Resident #13 was accurate. On 8/17/22 at 9:32 AM, the ED confirmed there were documentation issues with the CNAs charting showers. The ED confirmed there were some missing showers.

Based on observation, policy review, and resident and staff interview, it was determined the facility failed to ensure infection control prevention practices were consistently implemented and maintained to provide a safe and sanitary environment. This was true for 17 of 19 residents (#1 - #17) whose meals and/or room cleaning services were observed. This failure created the potential for negative outcomes by exposing residents to the risk of infections, including COVID-19. Findings include: 1. The facility's Hand Hygiene for Residents policy, revised 11/2020, directed staff to encourage and assist resident as needed to ensure proper hand hygiene through hand washing or the use of alcohol-based hand rub prior to handling and/or consumption of food or drink. This policy was not followed: a. On 11/18/20 from 11:50 AM to 12:20 PM, lunch trays in the Clearwater hallway were served to residents. The following was observed: -At 11:50 AM, CNA #3 delivered and set up Resident #1's meal on his overbed table. CNA #1 did not offer hand hygiene to Resident #1 prior to his meal. -At 11:55 AM, CNA #3 delivered and set up Resident #2's meal on her overbed table. CNA #3 did not offer hand hygiene to Resident #2 prior to her meal. -At 11:57 AM, CNA #4 delivered and set up Resident #3's meal on his overbed table. CNA #4 did not offer Resident #3 hand hygiene prior to his meal. At 12:06 PM, Resident #3 was eating his meal. An unopened packet of a disposable moist towelette was on his tray. Resident #3 said he was not offered hand hygiene prior to eating his meal. -At 12:00 PM, CNA #3 delivered and set up Resident #4 and Resident #5's meals on their overbed tables. CNA #3 did not offer hand hygiene to Resident #4 and Resident #5 prior to their meals. -At 12:05 PM, Resident #6 was eating her meal, an unopened packet of a disposable moist towelette was on her lunch tray. CNA #4 then entered the room and delivered and set up Resident #7's meal on her overbed table. An unopened packet of a disposable moist towelette was on her tray. CNA #4 did not offer hand hygiene to Resident #7 prior to her meal. -At 12:07 PM, CNA #4 delivered and set up Resident #8's meal on her overbed table. CNA #4 did not offer hand hygiene to Resident #8 prior to her meal. At 12:09 PM, Resident #8 was eating her meal. An unopened packet of a disposable moist towelette was on her lunch tray. Resident #8 said she was not offered hand hygiene prior to eating her meal. -At 12:09 PM, CNA #5 delivered and set up Resident #9's meal on her overbed table. CNA #5 did not offer hand hygiene to Resident #9 prior to her meal. -At 12:09 PM, Resident #8 was eating her meal. An unopened packet of disposable moist towelette was on her lunch tray. Resident #8 said she was not offered hand hygiene prior to eating her meal. -At 12:10 PM, Resident #5 was eating her meal. An unopened packet of disposable moist towelette was on her lunch tray. -12:12 PM, CNA #6 delivered and set up Resident #10's meal on her overbed table. CNA #6 did not offer hand hygiene to Resident #10 prior to eating her meal. -At 12:15 PM, CNA #4 delivered and set up Resident #11's meal on her overbed table. CNA #4 did not offer hand hygiene to Resident #11. On 11/18/20 at 12:16 PM, CNA #5 and CNA #6 said they did not offer hand hygiene to residents prior to the residents eating their meals. On 11/18/20 at 12:20 PM, CNA #4 said she did not offer hand hygiene to residents when she delivered and set up their meals. CNA #4 said she should have offered hand hygiene to the residents prior to their meals. -At 12:22, CNA #3 collected Resident #12's lunch tray and placed it inside a plastic bag. An unopened packet of a disposable moist towelette was on the lunch tray. At the time of the observation CNA #3 said she did not offer hand hygiene to residents when she delivered and set up their trays. b. On 11/18/20 from 11:58 AM to 12:02 PM, lunch trays in the Snake River hall were served to residents. The following was observed: -At 11:58 AM, CNA #1 delivered and set up Resident #14's meal on her overbed table. CNA #1 did not offer or remind Resident #14 to perform hand hygiene prior to her meal. -At 12:00 Noon, CNA #2 delivered and set up Resident #15's meal on her overbed table. CNA #2 did not offer or remind Resident #15 to perform hand hygiene prior to her meal. -At 12:02 PM, CNA #1 delivered and set up Resident #16's meal on her overbed table. CNA #1 did not offer or remind Resident #16 to perform hand hygiene prior to her meal. On 11/18/20 at 12:08 PM, CNA #1 said she had not offered or reminded Resident #14 to perform hand hygiene. CNA #1 said she had not offered or reminded Resident #16 to perform hand hygiene. CNA #1 said Resident #16 had performed hand hygiene when she went to the bathroom. On 11/18/20 at 12:10 PM, CNA #2 said she had not offered or reminded Resident #15 to perform hand hygiene. CNA #2 said Resident #15 had used the bathroom before the meal so may have washed her hands then but was not sure. On 11/18/20 at 4:07 PM, the Administrator with DON present, said hand hygiene should be offered to the residents before and after meals. 2. The facility Housekeeping Services policy for routine cleaning, updated 10/7/20, directed housekeeping staff to: * Change cleaning cloths for a new, wetted cloth when they were no longer saturated with solution. * Clean surfaces and objects before disinfecting. Disinfection should be done using a facility-approved cleaning solution. The policy also documented an alternative cleaning agent for use in a crisis situation, and directed staff to prepare a 10% solution from sodium hypochlorite solution (bleach). When using the approved bleach sanitizer and disinfectant, staff were instructed to stir and transfer the solution to a storing container used to spray and disinfect surfaces. The Sysco Classic Germicidal Ultra Bleach cleaning solution manufacturer's direction for use stated to first clean hard, non-porous surfaces by removing gross filth, apply a 1:10 bleach solution (1 part bleach to 10 parts water), let the solution stand on the surface for 10 minutes, and then rinse and let the surface air dry. The facility's policy and manufacturer's directions were not followed. a. On 11/18/20 at 8:45, Housekeeper #2 said for daily cleaning she used a 1:10 bleach solution for surfaces, and was trained to spray the cloth and then wipe the surfaces. Housekeeper #2 donned a fresh pair of gloves, extracted a fresh cloth from a bag and the spray bottle with the 1:10 bleach solution from the housekeeping cart. Housekeeper #2 entered room [ROOM NUMBER]. Housekeeper #2 sprayed the dry cloth with 1:10 bleach solution 4 times and wiped down Resident #17's dresser, closet door face and handle, bedside table and then put the cloth away. Housekeeper #2 extracted another dry cloth, sprayed it 4 times with the 1:10 bleach solution, and wiped down the edge of the privacy curtain, call light and chord, and TV remote and chord. She left the room and returned to the cart, put away the 1:10 bleach solution spray bottle and cloth, and moved down the hall with the housekeeping cart. Housekeeper #2 did not wipe down the surfaces in Resident #17's room before applying the disinfectant and did not apply a sufficient amount of the bleach solution to the surfaces to allow the solution to stand on the surface for 10 minutes. b. On 11/18/20 at 11:20, Housekeeper #1 sprayed a white dry towel several times with 1:10 bleach solution and wiped Resident #13's overbed table. Housekeeper #1 then took another dry white towel and sprayed it several times with 1:10 bleach solution and wiped Resident #13's dressing table. Housekeeper #1 used the same towel to wipe Resident #13's bedside table. Housekeeper #1 then took another dry white towel and sprayed it several times with 1:10 bleach solution and wiped Resident #13's bathroom door. Housekeeper #1 then mopped Resident #13's floor and when she finished left the room. On 11/18/20 at 11:42 AM, Housekeeper #1 said she used at least three towels per resident room and sprayed it with a 1:10 bleach solution to wipe their furniture. Housekeeper #1 said the towel was not wet but she made sure it was damped before she used it to wipe the furniture in the residents' rooms. Housekeeper #1 and Housekeeper #2 did not wipe down the surfaces in the rooms of Resident #13 and Resident #17 before applying the disinfectant as directed in the facility's policy, and did not apply a sufficient amount of the bleach solution to the surfaces to allow the solution to stand on the surface for 10 minutes as per the manufacturer's instructions. On 11/18/20 at 4:07 PM, the DON said they expected housekeeping staff to use cleaning products per the product manufacturer's recommendations. On 11/19/20 at 9:00 AM, the ICP said housekeeping staff were to apply the bleach solution with a cloth and let it sit for 10 minutes for the bleach to take effect. The cloth must be fairly wet but not dripping and be visible on the surface for 10 minutes. The ICP said she understood it would not be wet on the surface the whole time but it continued to kill infectious pathogens. On 11/19/20 at 9:10 AM, the Acting Environmental Director said if after 5 minutes the surface sprayed with the bleach solution was dry, the expectation was that the housekeeper wipe the surface and then re-wet the surface with the bleach solution. The Acting Environmental Director said the process was to wipe the surface with a wet cloth, wait the required kill time, and then re-wipe the surface to remove the remaining solution.

Based on staff interview and record and policy review, it was determined the facility failed to ensure a bed hold notice was provided to the resident or their representatives upon transfer to the hospital. This was true for 1 of 1 resident (Resident #19) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time. Findings include: The facility's Bed Hold policy, undated, stated the policy applied to all residents, regardless of payment source. The policy stated the notice of a bed hold was provided to the resident and if applicable to their representative, at the time of transfer, or in cases of emergency transfer, within 24 hours of the transfer. This policy was not followed. Resident #19 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A Nurse's Progress Note, dated 11/9/20 at 4:10 PM, documented Resident #19 tested positive for COVID-19 and she was transferred to the facility's COVID-19 unit. A Nurse's Progress Note, dated 11/10/20 at 7:54 PM, documented Resident #19's oxygen saturation (the amount of oxygen in the bloodstream) was 84% with continuous oxygen via nasal cannula. Resident #19's physician was notified and ordered to send her to the hospital. Resident #19's record did not include documentation that a bed hold notice was provided to her or to her representative when she was transferred to the hospital. On 11/18/20 at 3:30 PM, the DON said a bed hold notice was provided to the residents upon their admission to the facility and upon transfer to the hospital. The DON said she was unable to find the bed hold notice for Resident #19.

Based on observation, interview, and record review the facility failed to implement facility policy and procedures to ensure hand washing/hand hygiene between glove chnages and use of PPE for transmission-based precautions in accordance with guidelines established by Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) for the prevention of COVID 19 transmission. These failures placed residents on two of four units at risk for exposure to COVID-19 and other communicable illness. Findings include: During the entrance interview on 5/5/20 the facility Administrator and the DON (Director of Nursing) said the facility currently had an outbreak of COVID-19 infection and all residents were tested . The administrator said the 400 hall was now clear with all residents asymptomatic for 17 days. The transitional care 200 hall was empty. The 400 Hall was a secured special care unit primarily for care of residents with dementia and was COVID-free. The 400 hall had dedicated staff with a separate entrance and break room. The 300 hall was used as the isolation wing. The DON identified 16 residents on isolation droplet precautions and residents who have resolved COVID and are considered recovered on the 300 hall. The DON identified 4 residents on the 400 hall and 1 resident on the 100 hall who recovered. The DON said CDC (Centers for Disease Control and Prevention) now required 10 days after last symptom to be considered recovered but the facility waits 14 days. DON said most of the residents are nearing the end of the 14 days. On 5/5/20 at 10:30 AM during observation on the 100 hall housekeeper HK1 exited resident room [ROOM NUMBER], placed soiled cleaning cloths in a bag on the housekeeping cart and removed his/her gloves. Without washing hands or using alcohol based hand rub (ABHR), HK1 put on new gloves, prepared a mop and re-entered room [ROOM NUMBER] to mop the floor. HK1 wore a facemask. At 10:45 AM observation revealed HK1 exited resident room [ROOM NUMBER] wearing the facemask and gloves. HK1 placed the cleaning cloths in the bag then while wearing the same gloves, reached into his/her pocket to get the keys for the housekeeping cart. HK1 got clean cleaning cloths from the cart then removed his/her gloves. HK1 applied new gloves without first washing hands or using ABHR between glove changes. At 10:47 AM HK1 took a garbage bag to the trash bin on the housekeeping cart. HK1 refreshed the mop in the mop bucket and wrung the mop with the wringer device on the bucket then went back into room [ROOM NUMBER]. At 10:55 AM HK1 exited the room. HK1 spoke briefly with surveyor then went directly to room [ROOM NUMBER] to clean. HK1 put on new gloves without hand washing or ABHR. When HK1 exited room [ROOM NUMBER] he/she agreed to an interview. HK1 said he/she worked at the facility for only one week. HK1 said he/she received orientation and instruction regarding the job requirements including infection control. HK1 said he/she changed the mop water after about every four rooms but had to change the mop water after every room if they were isolation rooms. HK1 1 was asked if he/she washed hands or did wearing gloves replace hand washing. HK1 responded I do have this and showed a small bottle of ABHR that was on the housekeeping cart. Surveyor asked HK1 when he/she would use the hand sanitizer and HK1 said I am not a fan of the sanitizer, it dries out my hands. I prefer to wash my hands. When asked if hand hygiene was required between glove changes HK1 said yes it was but he/she preferred to wash his/her hands. Surveyor informed HK1 that he/she was not observed to wash hands and HK1 responded I have not and further stated as he/she pulled back a glove I can still smell it on my hands. I do not care for the sanitizer gel. When informed HK1 was not observed to wash his /her hands, HK1 said he/she had not. When asked where he would wash his/her hands HK1 said any bathroom or the staff breakroom. HK1 said he/she took four breaks a day so HK1 said he/she washed hands about 20 times a day. On 5/5/20 at 1:00 PM The DON (Director of Nursing) was informed of the observations and interviews with HK1 and RCM1. DON said she knew HK1 was new to the job but completed facility and job orientation and was expected to wash hands or use ABHR whenever indicated. DON confirmed hand washing or use of ABHR was required between glove changes. The DON said measures to address the COVID-19 spread were communicated to all staff. DON said she could not explain RCM1's interview responses. DON said RCM1 and re-educate if needed. At 11:25 AM licensed nurse (LN1) screened surveyor for re-entrance to facility at the 400 unit. LN1 pointed out the ABHR and directed that a face mask must be worn at all times. The 400 hall (dementia unit) was separated from the rest of the facility by closed cross-corridor doors. At 11:35 AM a staff member walked through the doors from the 300 hall. Nursing assistant (NAC1) immediately followed the staff down the hall and checked her temperature. Surveyor interviewed the staff member who said she was the Resident Care Manager (RCM1). When asked if she came from the 300 hall, RCM1 said she did. RCM1 said she was RCM for part of 300 hall and for the 400 unit and her office was on the 300 hall. When asked if it was OK to breech the separation for the 400 unit by opening the cross-corridor doors, RCM1 said I probably should have gone around to the courtyard entrance. RCM1 further said It has just not been made clear what is expected. RCM1 said she wore a mask and did not routinely do direct care and wore PPE when she did. NAC1 said anyone who came onto the 400 unit from the 300 unit should put on a gown. NAC1 said the 400 unit was COVID-free. Observed care on 5/5/20 at 4:20 PM outside room [ROOM NUMBER] had signage indicating droplet precautions: facemask, eye protection, gown and gloves. Two signs posted inside the room indicated droplet precautions sand enhanced barrier precautions. For enhanced barrier precautions staff must also wear gloves and a gown for the following high-contact resident care activities; dressing, bathing, transfers, and linen changes. The order to don (put on) was posted: gown, mask, goggles, gloves and to doff (remove) gloves, goggles, gown, and finally the facemask. A gown hung on a hook in the room labeled NAC. NAC2 put a surgical face mask on over the mask she already wore. Next NAC2 donned a gown. RCM2 brought goggles and face shields to the unit. NAC2 donned the face shield and finally gloves then entered the room [ROOM NUMBER]. When NAC2 exited the room, she removed the outer mask and face shield, then the gown, and finally the gloves. CNA2 hung the gown in the room on top of the gown that hung on the hook and finally removed the gloves. Surveyor quetioned and RCM2 cued NAC2 to discard both gowns in the room and directed staff to remove any gowns hanging in the rooms at the beginning of their shift to start with a clean gown. RCM2 explained that she was on the unit watching the staff to ensure compliance with transmission-based precautions (isolation/precautions) because the facility had new staff and had known COVID positive residents were recovering on the unit. At 5:00 PM on 5/5/20 observation revealed two isolation carts between resident rooms [ROOM NUMBERS]. As NAC2 doffed PPE to exit room [ROOM NUMBER] NAC2 removed the face shield and placed it in top of an open box of gloves on top of the isolation cart. NAC3 was preparing to enter the room next door and asked NAC2 if she was done with it (referring to the face shield). NAc2 said yes she was finished with it. When surveyor asked if it was sanitized, NAC2 said no it was not. NAC2 said she did not know NAC3 planned to use the face shield right at that time before she sanitized it. When asked where the face shield should be stored while awaiting sanitization, NAC2 said she should have placed a barrier on top of the cart first. NAC2 said she thought she contaminated the gloves too. NAC2 consulted RCM2 who directed to discard the opened box of gloves. NAC3 was observed to don gloves first then face shield and gown. When asked about the order to don PPE NAC3 said last week the corporate nurse instructed staff to don gloves first. In an interview at 5:15 PM on 5/5/20 the facility Infection Preventionist (IP) confirmed the prior week, the corporate nurse gave contradictory and confusing instruction to the staff regarding donning and doffing PPE. IP said staff should don and doff PPE according to the posted instructions. IP said the posted instructions were consistent with the current CDC guidelines. At 5:25 PM the DON concurred with IP and told IP to direct staff to follow the instructions posted by the facility to don and doff PPE.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents were assisted to perform standard hand hygiene measures, staff performed hand hygiene, and catheter tubing was kept off the ground to reduce the risk of infection. This was true for 5 of 21 (#2, #4, #26, #36, and #131) residents sampled for infection control. This failure created the potential for more than minimal harm by exposing residents to the risk of infection and cross-contamination. Findings include: The facility's Hand Washing policy, dated 2/12/16, documented when hands were visibly soiled or came into contact with bodily fluids to use soap and water. If hands were not visibly soiled, then use an alcohol-based cleaning product before direct contact with patients and after contact with patients' medical equipment. 1. On 7/23/18 at 5:27 PM, during the dinner meal in the facility's Secured Unit dining room, Resident #2 was observed to bend over, scoop up a white food substance off the floor with her right hand and licked it off her fingers. CNA #4 had her back to Resident #2 during this time, then turned around, noticed the residue on the resident's fingers and used a napkin to wipe off the resident's fingers. CNA #4 then directed Resident #2 to the table where the resident began to eat her meal while using her fingers and her utensils. Approximately one minute later, RMC #2 wiped up the remaining white food substance off the floor. On 7/23/18 at 6:06 PM and on 7/24/18 at 10:35 AM, CNA #4 said she used a dry napkin to wipe off whipped cream from Resident #2's hand and she assumed the whipped cream was from the resident's meal. On 7/26/18 9:16 AM, the DON said staff should have sanitized Resident #2's hands when staff were not sure where the food came from. 2. On 7/24/18 at 12:36 PM, Resident #131 had just left a table in the Secured Unit's dining room and was ambulating toward the dayroom in her wheelchair. Resident #131's lunch plate was on the floor right side up with some remaining food on it. CNA #3 picked up the plate with his left hand, touching the portion of the plate which came into contact with the floor, and placed the plate back on the table where the resident had been sitting. CNA #3 then grabbed Resident #131's wheelchair handles and assisted her into the dayroom. CNA #3 then placed a gait belt on Resident #26 and physically assisted her into a dayroom chair, took off the gait belt and then grabbed Resident #26's walker to move it out of the way. CNA #3 then grabbed Resident #36's wheelchair handles and assisted him into the dayroom. CNA #3 used his hands to lock Resident #36's wheelchair brakes, placed the gait belt on the resident and physically assisted him into a dayroom chair. CNA #3 did not wash his hands or use hand sanitizer during these observations. On 7/24/18 at 12:44 PM and 7/25/18 at 11:12 AM, CNA #3 said Resident #131 had finished her meal and placed her plate on the ground. CNA #3 said he should not have placed the plate back on the table and should have used hand sanitizer after that and between assisting each of the residents. On 7/26/18 at 9:09 AM, the DON said she would expect staff to pick up the plate with a napkin or sanitize hands after picking the plate off the ground and to place the plate in the dirty dishes bin. The DON said staff were to sanitize their hands after performing resident cares, including after transfers. 3. The facility's policy and procedure for Foley Catheter Insertion, Removal, and Maintenance, dated 9/12/17, documented the following: * Secure the catheter to prevent movement and/or irritation and to decrease the risk of infection. * Do not leave the drainage bag laying on the floor. * A sterile, continuously closed drainage system should be maintained. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including retention of urine and [MEDICAL CONDITION] and [MEDICAL CONDITION] (weakness and paralysis) following cerebral infarction (stroke) affecting the left non-dominant side. Resident #4's annual MDS assessment, dated 4/16/18, documented she was cognitively intact, required one person physical assistance with personal hygiene, and had an indwelling catheter. Resident #4's physician orders, dated (MONTH) (YEAR), documented an order for [REDACTED]. Resident #4's care plan, dated 4/28/17, documented the licensed nurse was to monitor every shift for signs and symptoms of infection, [MEDICAL CONDITION], or changes in output from the Foley catheter. On 7/24/18 at 11:02 AM and on 7/25/18 at 9:28 AM, Resident #4 was sitting outside in the courtyard area. A section of the Foley catheter tubing was resting on the concrete surface of the ground. On 7/25/18 at 9:30 AM, CNA #1 said the Foley catheter bag or tubing should not be on the ground. On 7/25/18 at 9:33 AM, RN #1 said the Foley catheter bag and tubing should not be on the ground or contact the ground, and that it was an infection control issue. On 7/25/18 at 9:35 AM, RCM #1 said the Foley catheter bag and tubing should always be off the floor and staff were educated about that. RCM #1 said it was not a good idea for the Foley catheter tubing to be on the ground. Approximately 30 minutes later, RCM #1 said she looked at Resident #4's Foley catheter tubing and it was on the ground, and they would secure it so it did not touch the ground.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure expired medications and stool culture kits were not available for use or administration to residents. This was true for 1 of 4 medication storage rooms reviewed for expired medications and biological products. This failed practice had the potential to effect 22 of 22 sampled residents (#1, #2, #4, #8, #13, #15, #17, #22, #40, #48, #49, #52, #53, #59, #62, #65, #66, #70, #72, #74, #231, #233) who resided in the facility, who could receive expired medications and/or biological products. This failed practice created the potential for harm should residents receive expired medications and/or biological products with decreased efficiency. Findings include: A Laboratory Supplies policy undated, documented the DON expected staff to check expiration dates prior to using expired laboratory tests. On 7/26/18 at 11:42 AM, an unopened bottle of multi dose antacid liquid was found with an expiration date of 2/2018. On 7/26/18 at 12:25 PM, two Zinc-PVA/ Formulation O&P collection Kits (stool culture), were found to be expired with an expiration date of 3/2018, On 7/26/18 at 3:30 PM, the DON stated she expected her staff to check expiration dates on all pharmaceuticals and biological products before use and on a regular basis.

Based on observation, resident, family, and staff interview, review of the facility's Wound Care Resource Manual, and record review, it was determined the facility failed to ensure professional standards of practice were followed for 2 of 18 residents (#70 and #231) reviewed for standards of practice. Resident #70's leg wound treatments were provided without physician orders. Resident #231's [MEDICATION NAME] order was changed without a physician's orders [REDACTED]. Findings include: 1. Resident #231 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #231's care plan did not address her heart failure or hypertension. Resident #231's Physician orders [REDACTED]. The patch was to be applied at 9:00 AM and removed at 9:00 PM . On 7/24/18 at 9:45 AM, LPN #1 was observed as she brought a new [MEDICATION NAME] to place on Resident #231's chest. LPN #1 removed a button to expose where the patch was placed on Resident #231's chest and saw a patch was still in place from the previous day. LPN #1 stated, Oh, the previous shift must have forgotten to remove the patch. LPN #1 removed the patch from the day before and began to place the new patch. Resident #231's family member was present at the bedside and asked the nurse to please not place the new patch on the resident. Resident #231's family member requested the [MEDICATION NAME] be applied at night and removed in the morning. LPN #1 stated she would correct the order. Resident #231's 7/18/18 through 7/25/18 MAR documented her [MEDICATION NAME] was administered. Resident #231's [MEDICATION NAME] order was documented on the MAR. The MAR documented apply at 9:00 AM and it was crossed out with a hand-written word remove. The remove was crossed out and apply was hand written in for 9:00 PM. No time was documented as to when the change was made. Resident #231's Physician orders [REDACTED]. The patch was to be applied at 9:00 PM and removed at 9:00 AM. On 7/26/18 at 11:59 AM, the DON stated the [MEDICATION NAME] should be changed per physician orders. The DON stated she would ask about an order for [REDACTED]. The DON stated the nurse should not have attempted to place a new patch on when the previous patch was in place. On 7/26/18 at 3:12 PM, RCM #1 stated she started the process to change the administration time of the [MEDICATION NAME] on 7/26/18, not on 7/24/18. RCM #1 stated the other nurse (LPN #1) should have initiated the order change on 7/24/18. 2. The facility's Interdisciplinary Team Approach from the Wound Care Resource Manual, dated 2/25/15, documented All disciplines focus on assessment, planning, and implementing, and documenting care. The facility's Evaluations, Screenings, and Assessments from the Wound Care Resource Manual, dated 11/2017, documented the following: * All residents receive a weekly skin check by licensed staff. * Appropriate disciplines are notified of skin breakdown or the resident's risk of skin breakdown. * Nursing coordinates the response to resident's skin needs by the following means: implementing appropriate [MEDICATION NAME] measures when there is an identified risk, referring the resident to restorative and therapeutic programs when medically directed, and medically directed treatment for [REDACTED]. Resident #70 was admitted to the facility on [DATE] with multiple diagnoses, including muscle weakness and other abnormalities of gait and mobility. Resident #70's care plan, dated 3/30/15, directed staff to complete a weekly skin assessment, monitor per the treatment record, document positive results in the nurse's notes, and notify the family/physician. Staff were directed to complete all treatments per the physician orders [REDACTED]. Resident #70's quarterly MDS assessment, dated 4/6/18, documented the following: * Moderate cognitive impairment. * Skin tear(s) was present. * There was application of nonsurgical dressings. Resident #70's quarterly MDS assessment, dated 7/3/18, documented the following: * She was cognitively intact. * There were no skin problems. * There was application of nonsurgical dressings. Resident #70's physician orders, dated (MONTH) (YEAR), documented the following was ordered on [DATE]: If new skin issues noted fill out (the) appropriate skin sheets. Resident #70's TAR (Treatment Administration Record), dated (MONTH) (YEAR), documented the following: * Treatment orders for a skin tear to the right shin from 3/4/18 were noted as Resolved and initialed by a staff member. * On 7/24/18: Right shin-clean with NS, cover with [MEDICATION NAME] One- leave in place- change non-adherent pad secured with paper tape daily until resolved. Change PRN loose or soiled. Resident #70's Weekly Skin Integrity Data collection documented the following: * On 4/29/18: Skin tear on right shin, 0.25 by 0.2 improved, leave open to air, and resolved. * On 7/7/18: Skin intact. * On 7/24/18: New maceration (softening of the skin from contact with moisture) from dressing, new treatment on that day. On 7/24/18 at 10:14 AM, Resident #70 had a Band-aid dressing that was dated 7/20/18 on her right lower leg with redness noted in the right lower extremity. Resident #70 said she must have bumped into something. There was no documentation in Resident #70's clinical record regarding a Band-aid or wound being present on the right lower extremity on 7/20/18. On 7/24/18 at 10:29 AM Resident #70 said she did not remember what happened to her right lower leg. RCM #1 removed the Band-aid, and a shallow open area was present on the right shin area. RCM #1 said she would apply a [MEDICATION NAME] and gauze dressing with paper tape and she would write an order for [REDACTED].#1 said there was not an order for [REDACTED].#70 having a Band-aid in place. RCM #1 said she would have the physician look at the wound and sign the order the next time she came in, and the physician was expected to come in later that day. RCM #1 applied the dressing as she previously described. On 7/25/18 at 1:43 PM, RCM #1 said a nurse applied the Band-aid to Resident #70's right lower leg as a preventive measure in case the resident bumped it. RCM #1 said the nurse should not have applied the Band-aid without obtaining an order. RCM #1 said she thought Resident #70 had a skin tear in the same area a long time ago, and she thought the current wound was a macerated area over an old skin issue.

Based on observation, staff interview, policy and procedure review, and resident record review, it was determined the facility failed to ensure adequate supervision of residents to prevent falls and that fall prevention measures were followed. This was true for 1 of 4 sampled residents (#70) reviewed for falls when a resident experienced multiple falls in the facility. This failure created the risk for harm should residents sustain injuries from falling. Findings include: The facility's undated policy and procedure for Fall Risk Management documented the following: * The admitting nurse completes the initial Fall Risk Assessment within 24 hours of admission. * If the score is 10 or greater on the Falls Risk Assessment or if the resident has a history of falling prior to admission, the resident is at high risk for falls. The admitting nurse will initiate the care plan regarding the resident's current status and the initial interventions to minimize the potential for falls and injury. * A Fall Risk Assessment is completed after a fall with serious injury, significant change, quarterly, and as needed. * If the score is greater than 10 on subsequent Fall Risk Assessments, the care plan is updated to show the resident's current status and the necessary interventions. The care planned interventions are communicated to staff members by inservices, orientation, shift reports, care plan meetings, and/or staff meetings. Resident #70 was admitted to the facility on [DATE] with multiple diagnoses, including muscle weakness and other abnormalities of gait and mobility. Resident #70's quarterly MDS assessment, dated 4/6/18, documented the following: * Moderate cognitive impairment. * One person physical assist when walking in corridor and locomotion off unit. * Not steady, but able to stabilize without human assistance with moving from seated to standing and surface to surface transfers. * Not steady, only able to stabilize with human assistance with walking, turning around and facing the opposite direction while walking, and moving on and off the toilet. * Use of a walker and wheelchair. * Two or more falls with no injury since admission or the prior assessment. * One fall with injury (except major) since admission or the prior assessment. Resident #70's quarterly MDS assessment, dated 7/3/18, documented the following: * She was cognitively intact. * One person physical assist when walking in corridor. * Not steady, but able to stabilize without human assistance with moving from seated to standing and surface to surface transfers. * Not steady, only able to stabilize with human assistance with walking, turning around and facing the opposite direction while walking, and moving on and off the toilet. * Use of a walker and wheelchair. * One fall with no injury since admission or the prior assessment. Resident #70's physician orders, dated (MONTH) (YEAR), documented the 4 P's (pain, potty, positioning, placement of personal items) were to be completed hourly between 6:00 PM and 6:00 AM. The order was dated 3/12/18. Resident #70's current care plan directed staff to: * Perform a Fall Risk Assessment upon admission, quarterly, and upon incident. * Ensure the resident was aware of her call light location. * Ensure the bed was at the appropriate height for transfers. * If declines or falls occurred, assess for injuries, level of consciousness, signs/symptoms of infection, review medications, check vital signs, review recent lab results, request a urine culture if a urinalysis was ordered, and notify the physician of abnormalities. * Document falls in the nurses' notes per the facility protocol. * Ensure footwear was properly fitted and was non-skid when out of bed. * 4 P's from 6:00 PM to 6 AM. Resident #70's Fall Risk Evaluations documented the following: * When (the) resident's total score is 10 or more, interventions should promptly be put in place. * On 2/3/18 the fall risk score was 13. * On 3/12/18 the fall risk score was 15. * On 4/18/18 the fall risk score was 18. * On 7/20/18 the fall risk score was 9. An Accident and Incident (A and I) report, dated 2/3/18 at 11:00 AM, documented Resident #70 fell in her room. She was found sitting on the floor next to her bed and stated she slipped while attempting to get out of bed. The slippers were removed, which had slick soles, and the bed was at the appropriate height. Interventions in place prior to the fall included bilateral cane rails, increased staff assistance, non-skid footwear, education about falls, an x-ray of the elbow, bed against the wall, continue to ensure non-skid slippers were on, and frequent checking. Current intervention were to include removing slippers that did not have a gripping surface, continue to monitor for slick or plain footwear, encourage non-skid footwear, alert charting and neuro checks. A therapy screening was completed, which indicated the resident was not appropriate for skilled therapy interventions. An A and I report, dated 3/12/18 at 4:15 AM, documented Resident #70 fell in her room. She was found sitting on the floor in stocking feet after she was heard banging on the closet door. She was on a one person assist to (the) wheelchair. She stated she slipped out of (the) w/c (wheelchair)/bed and landed on the floor. Interventions in place prior to the fall included bed at the appropriate height, locked wheelchair, non-skid socks, frequent checks at night, and anticipate needs. Current interventions were to include having the wheelchair nearby, non-skid socks or slippers, monitor for self transfers, add the 4 P's, licensed nurse to round every hour from 6 PM to 6 AM, alert charting, and neuro checks per protocol. A therapy screening was completed, which indicated the resident was not appropriate for skilled therapy interventions. An A and I report, dated 4/18/18 at 3:30 AM, documented Resident #70 fell in her room by her bed. A nurse walked by and heard the resident calling out for help, and she was lying on her right side by the night stand with one shoe on and one shoe off. The resident stated she fell when trying to put her shoe on. Interventions in place prior to the fall included bed at the appropriate height, non-skid footwear, call light within reach, hourly checks, wheelchair brakes locked, and wheelchair next to bed. Current interventions were to include alert charting and neuro checks, monitor for pain and changes, send in a urinalysis to check for a urinary tract infection, and assessment for use of one bed cane rail per the resident's request. The bed cane rail was installed on 4/24/18. A therapy screening was completed, which indicated the resident may have benefited from skilled therapy interventions, and an order for [REDACTED].>A Progress Note, dated 7/20/18 at 12:02 AM, documented Resident #70 was found on the floor by her bed. The resident stated she slid off the bed, and she was wearing socks from home. She was assisted off the floor to her wheelchair and assisted to the restroom. Non-skid socks were provided. A Progress Note, dated 7/20/18 at 12:15 PM, documented slick socks were discussed with Resident #70's family member, and all socks except non-skid is a good intervention for these kinds of falls. On 7/26/18 at 10:05 AM, Therapy Staff #1 said Resident #70 had been ambulating with a front-wheeled walker with assistance from CNAs. Therapy Staff #1 said an occupational therapy assessment was last performed on 6/27/18, and there were no current referrals for therapy. On 7/26/18 at 10:49 AM, the Therapy Director said Resident #70 last received physical therapy on 3/15/18. On 7/26/18 at 4:28 PM, the Therapy Director said Resident #70 was not involved in therapy beyond the initial evaluation because there had not been much change in her status. The Therapy Director said the resident liked fuzzy slippers, and the resident and her family were educated about the socks and about obtaining assistance to get up. On 7/27/18 at 7:53 AM, RCM #1 said Resident #70 had fallen more this year, mainly because she was more active and was walking more. RCM #1 said the main cause of Resident #70 falling was her socks, and it mostly happened at night. RCM #1 said the resident would use her call light at times, perhaps 50% of the time she would call for help, and staff looked in when they walked by and would intervene if they saw something happening. RCM #1 said Resident #70's family member continued to bring in slippery socks, facility staff previously talked to the family about the socks, and she was going to talk with the family again. RCM #1 said the CNAs applied Resident #70's socks, and the resident liked regular socks. RCM #1 said the only other option to help prevent Resident #70 from falling was a one-to-one staff assignment, but she was not sure how practical that would be for the resident's privacy and needs. RCM #1 said the 4 P's were initiated for Resident #70 on 7/6/18. The A and I report, dated 3/12/18 at 4:15 AM, included documentation the 4 P's were to be added as a intervention following Resident #70's fall on that date. Resident #70's physician orders, dated (MONTH) (YEAR), documented the 4 P's (pain, potty, positioning, placement of personal items) were ordered on [DATE], and were to be completed hourly between 6:00 PM and 6:00 AM. The 4's were added to Resident #70's care plan on 7/6/18, 3 months and 24 days after ordered by the physician. On 7/27/18 at 7:53 AM, a copy of the A and I report was requested from RCM #1 regarding Resident #70's fall on 7/20/18. The facility did not provide a copy of the A and I report.

Based on staff interview and record review, it was determined the facility failed to ensure appropriate information was documented in the resident's record and provided to the resident upon discharge. This was true for 1 of 3 residents (#80) reviewed for discharge from the facility. This failure created the potential for harm and inappropriate care due to incomplete documentation related to the resident's discharge. Findings include: 1. Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #80 was discharged from the facility on 4/25/18. A Nurse's Progress Note, dated 4/25/18 at 10:27 AM, documented Resident #80 was discharged home and her left leg was wrapped with ace bandages. The note documented Resident #80 was instructed to leave the bandage in place until her appointment with a physician in (MONTH) (YEAR). When asked to provide a discharge summary for Resident #80, the facility provided a packet that included the following documentation: physician orders, recapitulation of stay, and a Discharge and Transition Form. The Discharge Summary, dated 4/25/18, documented Resident #80 was discharged on [DATE]. The form did not include information of a physician's visit scheduled following discharge from the facility and did not provide the resident with contact information of the physician. The summary documented if her leg swelled then home health may be an option for Resident #80. On 7/26/18 at 9:37 AM, the DON stated the information provided was all the information she could find regarding Resident #80's discharge. On 7/26/18 at 3:48 PM, the DON stated Resident #80 chose not to use home health services. The DON stated she did not know why the discharge summary documented home health for the leg wrap. The DON stated the physician's appointment was not on the discharge paperwork.

Based on observation, record review, facility policy review, and staff interview, it was determined the facility failed to maintain an environment that enhanced residents' dignity and respect when staff placed clothing protectors on residents without their permission and when staff did not address residents by their preferred name. This was true for 3 of 3 (#2, #40 and #42) residents sampled for dignity and had the potential to affect all residents who resided in the facility's Special Care Unit. This practice created the potential for psychosocial harm if residents experienced embarrassment or a lack of self-esteem due to their appearance or how they were addressed. Findings include: The facility's Dignity and Meal Service policy, dated 6/7/08, directed staff to provide residents with clothing protectors when needed and to focus on residents as individuals when speaking to them. 1. Clothing protectors were placed on residents without first asking their permission, as follows: a. Resident #42 was admitted to the facility on [DATE] with multiple diagnoses, including dementia with behavioral disturbances. Resident #42's current care plan directed staff to use a clothing protector at all meals, per family wishes. On 7/24/18 at 12:05 PM, during lunch in the facility's Secured Unit dining room, CNA #2 placed a clothing protector on Resident #42 without asking her permission. On 7/25/18 at 9:05 AM, CNA #2 said she thought since Resident #42's clothing protector was addressed her care plan she did not need to ask the resident's permission and the resident would probably not really respond if she was asked. b. Resident #40 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION]. Resident #40's current care plan directed staff to promote dignity, stated she could answer yes and no questions, and wore a clothing protector with meals, per family request. On 7/24/18 at 12:07 PM, CNA #3 assisted Resident #40 in her wheelhair in the Secured Unit hallway and stopped near the dayroom. CNA #3 told Resident #40 that he would go and get a clothing protector. CNA #3 then picked up a clothing protector on a shelf in the dining room, brought it back, and placed it on Resident #40 without asking her permission. On 7/25/18 at 11:11 AM, CNA #3 said he did not ask Resident #40 if she wanted a clothing protector because Resident #40's care plan said she used one. On 7/26/18 at 9:01 AM, the DON said staff should ask residents if they wanted clothing protectors. The DON said even if residents' care plans directed staff to use clothing protectors, the residents still had a choice to use them or not. 2. On 7/24/18 at 11:57 AM, while near the facility's Secured Unit dayroom, CNA #3 assisted Resident #2 with hand sanitizer and told the resident to, rub your hands together Sweetie. CNA #3 then said to Resident #2, Come on Sweetheart, lets walk down to lunch. On 7/25/18 at 11:08 AM, CNA #8 said he called all the female residents Sweetie and the male residents big boy or something similar. On 7/26/18 at 9:05 AM, the DON said staff should call residents by their preferred name and not to use terms of endearment when addressing residents.

Based on observation, resident and staff interview, and record review, it was determined the facility failed to ensure a method for evaluating the effectiveness of residents' pain management plans was in place for 2 of 3 residents (#1 and #231) sampled for pain. This failure created the potential for harm if residents experienced ongoing severe pain or increased pain and the facility did not identify it. Findings include: 1. Resident #231 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan area addressing Resident #231's pain, dated 7/18/18, documented staff were to evaluate the effectiveness of pain interventions and provide pain medications as ordered. Resident #231's physician order, dated 7/17/18, documented Resident #231 was to receive a 1000 mg tablet of [MEDICATION NAME] orally three times a day for chronic pain. A Fax Order Request, dated 7/22/18, documented Resident #231 was currently receiving [MEDICATION NAME] for back pain due to her kyphosis (curvature in upper portion of the back), and she stated the pain medication was not providing adequate pain control. Resident #231's 7/17/18 through 7/26/18 MAR indicated [REDACTED]. Resident #231's pain levels on the 7/17/18 through 7/23/18 evening shift documented her pain levels were rated at five and six. Resident #231's pain level on the 7/23/18 night shift was rated at a level 8. Resident #231's pain level on the 7/24/18 morning shift was rated at a level 10. Resident #231's pain level on the 7/25/18 morning shift was rated at a level 8, and on the morning shift of 7/26/18 her pain was rated at a level 9. On 7/23/18 at 4:33 PM, Resident #231 was complaining of severe back pain and wanted to lay down. Resident #231 stated she was miserable and her pain was a 10 out of 10. On 7/24/18 at 9:24 AM, Resident #231 was sitting in the therapy room in her wheelchair with her head bent over her chest and appeared asleep. The therapist was observed asking Resident #231 to please stand up with her walker. Resident #231 stood up and sat down quickly in her wheelchair from exhaustion. Resident #231 complained of pain in her back and dizziness. On 7/24/18 at 9:34 AM, Resident #231 stated she had severe pain of 10 out of 10 in her back. On 7/24/18 at 9:40 AM, LPN #1 provided Resident #231 with [MEDICATION NAME] and Resident #231 stated her pain was at a 10 out of 10. On 7/24/18 at 9:57 AM, Resident #231 stated the [MEDICATION NAME] was not working for the pain control. Resident #231 stated she told staff members about the pain control issue and it had not been resolved yet. A 7/24/18 physician order [REDACTED]. On 7/24/18 at 11:45 AM, RCM #1 stated she was not aware of the increased pain Resident #231 was experiencing until 7/24/18. RCM #1 stated the physician was called about her increased pain and an order for [REDACTED].#1 stated she had not thought about other non-pharmacological interventions tried such as massage, heat, and cooling. RCM #1 stated she would speak with Resident #231 and the staff about utilizing those options. RCM #1 stated she spoke with Resident #231's family about trialing different positions while in bed and ensuring Resident #231 was positioned out of bed during meals. RCM #1 stated they would utilize additional pillows for Resident #231's positioning to try and help with pain control. RCM #1 stated she could not find documentation of other nonpharmacological interventions that the facility tried. RCM #1 stated she was not sure why there was a delay of two days from the date of the faxed order request (7/22/18) and the receipt of the physician's orders [REDACTED]. A Progress Note, dated 7/24/18 at 11:48 AM, documented Resident #231 was interviewed regarding her pain level. The note documented her pain level on 7/23/18 all day was a 10/10. The note documented Resident #231's family was contacted regarding her increased pain, and her family stated Resident #231 was 'hunched over' in bed while she was there. The note documented non-pharmacological heat or cold per resident preferences was suggested. On 7/26/18 at 9:52 AM, the DON stated Resident #231 had kyphosis and she was receiving the maximum dose of [MEDICATION NAME]. The DON stated staff should evaluate residents' pain levels and determine if the current medication was working timely. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 4/18/18, documented Resident #1 had a severe cognitive impairment and received PRN pain medications. The MDS assessment documented Resident #1 had frequent pain. Resident #1 did not have a care plan regarding pain. Resident #1's physician orders [REDACTED]. * 650 mg of [MEDICATION NAME] tablet orally four times daily PRN for pain, ordered 10/21/17. * 50 mg of [MEDICATION NAME] every 4 hours PRN for pain ratings 3-5 out of 10, ordered 10/21/17. * 100 mg of [MEDICATION NAME] every 4 hours PRN for pain ratings of 6-10 out of 10, ordered 10/21/17. Resident #1's orders did not include a daily pain assessment. A Pain Assessment, dated 5/22/18, documented Resident #1 was not experiencing pain. On 7/24/18 at 10:22 AM, Resident #1 stated she was in pain and pointed to her joints when asked where it hurt. Resident #1's clinical record did not contain a daily pain assessment on the MAR indicated [REDACTED]. On 7/26/18 at 10:38 AM, the DON and RCM #2 stated Resident #1 did not require scheduled pain medications and RCM #2 stated Resident #1's pain was present in her knee when she walked. RCM #2 stated Resident #1 did not request pain medications very often and she did not have very much pain present. The DON stated nurses assess residents for pain when providing all medications and it was just not documented.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents receiving a psychoactive medication had an appropriate indication for use of the medication. This was true for 1 of 5 (#1) sampled residents who received psychoactive medications. This deficient practice created the potential for harm if residents received medications that may result in negative outcomes without clear indication of need. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 4/18/18, documented Resident #1 had a severe cognitive impairment and no signs and symptoms of depression. The care plan area addressing Resident #1's Mood and Behavior, initiated 11/10/17, documented Resident #1 had depression as evidenced by angry outbursts related to functional limitation. Resident #1's physician order, dated 11/28/17, documented Resident #1 was to receive 5 mg of [MEDICATION NAME] one time a day for depression. Resident #1 did not have a Behavior Monitoring flowsheet for (MONTH) (YEAR). Resident #1's (MONTH) (YEAR) Behavior Monitoring flowsheet documented no behaviors or signs of depression. Resident #1's physician order, dated 1/18/18, documented Resident #1 was to receive 10 mg of [MEDICATION NAME] one time a day for depression. Resident #1's (MONTH) (YEAR) MAR indicated [REDACTED]. Resident #1's 1/1/18 through 5/2/18 Behavior Monitoring flowsheets documented no behaviors or signs of depression. A Physician's Progress Note, dated 4/27/18, documented Resident #1 was sleeping well with a good appetite and good energy. The note documented Resident #1 was started on [MEDICATION NAME] for depression and anxiety and was doing much better after the initiation of the medication. The note documented Resident #1 was participating in physical therapy more and not calling her family as much. Resident #1's physician order, dated 5/2/18, documented Resident #1 was to receive 20 mg of [MEDICATION NAME] one time a day for depression. Resident #1's 5/3/18 through 7/25/18 Behavior Monitoring flowsheet documented one episode of depression on 5/4/18. Resident #1's 5/1/18 through 7/25/18 MAR indicated [REDACTED]. On 7/26/18 at 10:08 AM, the DON stated Resident #1 seemed more cheerful and she was depressed towards the ends of last year. RCM #2 stated Resident #1's family spoke with her physician about her depression. RCM #2 stated the family told the physician that Resident #1 still had signs and symptoms of depression and that she needed an increase in her depression medication. RCM #2 stated Resident #1 was not present when Resident #1's family spoke with the physician. RCM #2 stated Resident #1 had not exhibited signs and symptoms of depression that the staff had identified. RCM #2 stated Resident #1's normal activity was to stay in her room and visit with her family when they came to visit her. RCM #2 stated the family was requested to let the facility know when Resident #1 exhibited signs of depression.

Based on observation and staff interview, it was determined the facility failed to ensure staff demonstrated respect for residents' private space when entering residents' rooms without knocking on their doors. This was true for 1of 17 (#4) sampled residents and 2 (#21 & #22) random residents. This failed practice had the potential to negatively affect residents' psychosocial well-being. Findings include: On 7/25/16 from 1:55 pm to 1:58 pm, CNA #5 was observed entering Resident #4's room without first knocking on the door. Resident #4 was in bed and when CNA #5 approached. Resident #4 said, uh and visibly moved back on her bed. After a few seconds, CNA #5 left the room and told the surveyor who was outside the room that she had startled Resident #4. CNA #5 then walked into Resident #21's room without knocking, checked on Resident #21, who was in bed and then left the room. CNA #5 then crossed the hallway and entered Resident #22's room without knocking, checked on Resident #22, who was in bed and then left the room. On 7/25/16 at 1:58 pm, CNA #5 said she might not have knocked on the room doors in question.

Based on observation, record review and staff interview, it was determined the facility failed to ensure residents received adequate supervision to prevent falls with injuries. This was true for 2 of 6 (#s 1 & 8) residents sampled for falls. Resident #8 was harmed when the resident fell and suffered a fracture of the right distal femur. Additionally, the facility failed to comprehensively assess Resident #1's falls. Findings included: Resident #8 was admitted to the facility on [DATE], due to surgical intervention for a right hip and proximal fracture which resulted from a fall, with [DIAGNOSES REDACTED]. The resident's Admission MDS, dated [DATE], documented in part: *Cognition was moderately impaired, BIMS Score of 9. *Extensive assist of 2+ persons for bed mobility, transfer and toilet use. *Extensive assist of 1 person for dressing, personal hygiene and bathing. *Functional limitation of range of motion in the lower extremity. *Frequently incontinent of bladder. *Always continent of bowel. The resident's Significant Change MDS, dated [DATE] (after a fall with injury), documented in part: * Cognition was severely impaired, BIMS Score of 5. * Extensive assist of 2+ persons for toilet use. * Total dependence with assist of 2+ persons for transfers and bathing. * Extensive assist of 1 person for bed mobility and dressing. * Balance during transitions and walking was not steady, only able to stabilize with staff assistance for moving on and off toilet and surface-to- surface transfer (transfer between bed and chair on wheelchair). * Functional limitation of range of motion in the lower extremity. * Frequently incontinent of bladder * Always incontinent of bowel. * Weight loss of 5% or more in the last month but not on physician- prescribed weight-loss regimen. In the three months since the resident was admitted to the facility, she experienced declines in mental functioning, ADL assistance, bowel incontinence and weight loss. Resident #8's medical record documented the following falls since her admission to the facility: 8/18/13, 9/11/13 and 10/15/13. The resident's Fall Risk Evaluation documented the resident was at risk for falls when the score of 10 or higher and interventions should be initiated. Resident #8's Fall Risk Evaluation documented a score of 22 on 7/7/13, 8/18/13 and 9/11/13. A score of 24 was documented on 10/15/13. Resident #8's Fall Risk Evaluation, dated 7/8/13, documented the following interventions were effective and did not require follow-up: 1) Low bed; 2) Non-skid footwear; and 3) Audible alarms. Resident #8's ADL Care Plan, dated 7/24/13, documented the resident "requires up to a one (1) person extensive assist with all ADLs requiring her to transfer, stand or walk." Resident #8's ADL Care Plan was updated on 9/17/13 to include: 1) Decline in ADL's R/T (related to) right femur fracture - non-weight bearing status. 2) Requires Hoyer lift for all transfers. 3) Non-weight bearing to right leg. 4) Keep right leg immobilizer in place at all times. An Incident Report for Resident #8, dated 8/18/13 at 12:45 PM, documented: Resident #8 was found on her knees next to the bed attempting to self transfer from her wheelchair to the bed. The resident had compression stockings on and removed the non-skid socks prior to transfer. Resident #8 demonstrated the ability to remove the pull tab alarm despite it being placed on her lower back. The bed was at the proper height. No injuries were noted and a MDS significant change was not required. The report documented "unknown" when the resident was last toileted. Resident #8's Fall Risk Evaluation, dated 8/18/13, was updated to include the following interventions were not effective and required follow-up: 1) Low bed; 2) Non-skid foot wear; 3) Audible alarms; and 4) Requested pressure pads from restorative. A social service note, dated 9/10/13 at 4:06 PM, documented "Completed 60 Day MDS per PPS guidelines. Rsdt shows for no overall significant changes in the areas followed by SS. Rsdt's BIMS screen scored a 8/15." An Incident Report for 9/11/13 documented: Resident #8 fell attempting to self transfer from her bed, her feet slipped and she slid to the floor. Non-skid foot wear were in place. ROM (range of motion) was completed with assist from an aide to bend the resident's leg to her chest without difficulty. In the AM, Resident #8 complained of pain in her ankle but denied pain in her hip, leg or knee, however, the knee was slightly swollen. Resident #8 was sent to (a local hospital) for evaluation related to an acute fracture of the right distal femur. The resident returned to the facility with orders for NWB (non-weight bearing) and an immobilizer to her right leg. However, surgery was not planned. The report documented Resident #8 had been toileted prior to her son's visit and the son did not inform staff of his departure. There was documentation a MDS significant change was not required. Resident #8's Fall Risk Evaluation, dated 9/11/13, was updated to include the following interventions: 1) Bed alarm - pressure; 2) Non-skid socks; 3) Bed at appropriate height; and 4) 4 P's with rounding (potty, pain, positioning if needed and place of equipment). NOTE: Frequency of rounding was not listed. A nursing note, dated 9/11/13 at 9:27 PM, documented "This evening resident had apparently self transferred to her bed and then was attempting to get up without assist. She slid off the bed and was found sitting on the floor with her back against the bed. No apparent injury." A nursing note, dated 9/12/13 at 7:21 AM, documented the resident complained of right leg pain from mid thigh, knee to ankle but denied hip or foot pain. The right leg was swollen and pain increased with weight bearing. Resident #8 was sent to the ER (emergency room ) for evaluation and treatment on 9/12/13. The final X-Ray report, dated 9/12/13, documented "Acute fracture of right distal femur just above distal tip of intra-medullary rod, with minimal displacement." A nursing note, dated 9/12/13 at 9:18 PM, documented the resident returned from the hospital to the facility with an immobilzer brace on her right leg, ordered to see an orthopedic physician and to be NWB (non-weight bearing). A nursing note, dated 9/17/13 at 10:03 AM, documented Resident #8 required a Hoyer lift for transfers, was not able to ambulate and was set up for an MDS significant change in status assessment which was E-Signed by the MDS Coordinator. The medical record documented a social service note E-Signed by the SS Designee, dated 9/30/13 at 8:03 AM, "SS Significant Change Assessment: This Rsdt (resident) slid out of bed on 9-12-2013 and later that day c/o (complained of) leg pain. The medical record included a Plan of treatment for [REDACTED]. Documentation included the resident previously received therapy after admission to the facility on [DATE] for an ORIF (Open Reduction Internal Fixation) of right femur fracture and was discharged from OT services on 8/23/13. The Plan of Treatment included Resident #8 had a recent fall with femur fracture and was changed to NWB status on her right lower extremity which significantly changed her transfer and ADL care. The resident needed to be transferred by Hoyer. There was documentation the Skilled OT assessment was needed to determine if Resident #8 could develop the ability to transfer with FWW (front wheeled walker) safely with the new NWB status. Resident #8's dietary note, dated 10/8/13 at 10:48 AM, documented the resident was reviewed for significant weight loss changes, down 5% in 30 days, with weight loss likely related to the 9/11/13 fall with fractured hip and pain changes. An Incident Report for Resident #8, dated 10/15/13 at 1:45 AM, documented: The resident was found on the floor beside her bed. The resident removed the pull tab alarm and stated she got up to use the bathroom when she slipped, fell , and then pulled the call light. The resident was found with bare feet, her Attends halfway on, and the side of the bed and floor were wet with urine. The Follow-Up section documented the facility discontinued the personal pull tab alarm. Motion alarms were placed at bedside with recommend-ations to use a bedside commode at night. Resident #8 was last toileted at 11:30 PM. However, the CNA's recreation of the last three hours before the fall documented the CNA checked on the resident, who was dry, and when asked if she needed to go to the bathroom, the resident said "no, I'm okay." Resident #8's Fall Risk Evaluation, dated 10/15/13, was updated to include the following interventions: 1) Bedside commode at night; and 2) Audible motion alarms to bathroom and bedside. A nursing note, dated 10/15/13 at 8:11 AM, documented the resident was found on the floor at 1:45 AM, had taken the pull tab alarm off and stated "I had to go to the bathroom in a hurry, I got up and slipped." The resident could not get up and turned the call light on. No injuries were noted at that time. On 10/24/13 at 2:10 PM, RCM #12 was interviewed regarding Resident #8's falls and the interventions which were implemented on 8/18/13, 9/11/13 and 10/15/13 after each fall. The surveyor asked RCM #12 about adding increased supervision for Resident #8. RCM #12 stated, the resident was already being monitored approximately every 1 hour for the 4 P's and she didn't think the facility could have done anything different. NOTE: There was no documentation in the resident's medical record about rounding with the 4 P's. On 10/28/13 the facility faxed additional information to the Bureau of Facility Standards for Resident #8's Incident Report (in-depth A&I) for 9/11/13, Weight Tracking Sheet, showing weights had stabilized, and information pertaining to the 9/11/13 MDS Significant Change assessment. The SS Designee stated, in a handwritten note, the BIMS screens were all completed in Resident #8's room, with the exception of the BIMS screen on 9/11/13, in which the resident scored a "5." The SS Designee stated the BIMS screen on 9/11/13 was given in the common area, off the Snake River Nurses station, after lunch. The SS Designee stated the resident was HOH (hard of hearing) and environmental noises in a common area could potentially affect the score. The fax contained additional information, however, the information did not resolve the concern of adequate supervision to prevent falls with injuries. Federal guidance at F-323 states, "Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is defined by the type and frequency of supervision, based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. Tools or items such as personal alarms can help to monitor a resident's activities, but do not eliminate the need for adequate supervision." Resident #8 experienced 3 falls in 3 months, since admission to the facility. The resident experienced a major injury which produced a MDS Significant Change assessment in the resident's mental and physical functioning. The facility failed to increase supervision as needed for the resident's condition. The resident experienced a fall, after the intervention of the 4 P's, and the facility did not increase the frequency of supervision. 2. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's 5/19/13 quarterly MDS coded severely impaired cognition, required one person supervision for most ADLs with the exception of bathing which was one person limited assistance, continent of bowel and bladder, and two falls with no injuries. The resident's 7/24/13 significant change MDS coded moderately impaired cognitive skills, required one person extensive assistance for most ADLs with the exception of walk in corridor which occurred one to two times, occasionally incontinent of bowel and frequently incontinent of bladder, and two falls one with no injury, one with injury but not major injury. The resident's 5/6/13 Fall Risk Evaluation form documented the resident's fall risk was 21. The form documented a score of 10 or higher was at risk. Subsequent Fall Risk Evaluations documented the resident's fall risk ranged from a total score of 18 to 34 from 5/6/13 to 10/14/13. The resident's Fall Risk Care Plan (CP) identified the 9/9/11 problem of, multiple falls in the past related to weakness, impaired dynamic balance, dementia with impaired decision making, unsteady gait, impulsivity, Res (resident) was anticipated to have further declines related to disease process. The problem goal was, will have no injury falls noted with interventions in place thru (through) 90 day follow up, 11/01/13. Problem approaches included, in part, the following: - Document fall in progress notes and notify MD and family - Hip guard waiver signed 12/29/11 - Encourage to wear non skid footwear when out of bed in room and when ambulating - Supervise gait for any unsafe actions, provide verbal cues for safety - If (Resident #1) should have any falls or signs and symptoms (s/sx) of declines, assess for s/sx of infection, assess meds (medications), obtain vital signs, and request a c&s (culture & sensitivity) on urine from MD - FYI MD (For Your Information) was aware of (Resident #1) significant decline and history of falls with need for additional help with ADL functions - Has rocking chair, monitor for safety sitting in and getting up from rocker - Bed against wall to accommodate personal space and homelike environment - Keep room free of clutter - Request verbal cues and reminders on blood sugars (BSs) & insulin injections and reassurance BSs were being managed - Fall Risk Assessment to be completed per facility protocol - Audible alarms in place, staff to respond quickly when sounding - Bed at correct height at all times for safety - Keep call light visible for assistance Note: Federal guidance at F323 specified, "...Implement interventions, including adequate supervision, consistent with resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident...Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is defined by the type and frequency of supervision, based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident." The facility's Incident Follow-Up Recommendation Form and Fall Scene Investigation Reports (Incident and Accident (I&A) Reports) contained, in part: -A section titled, Follow-Up. -A section titled, Describe initial interventions to prevent future falls. This section will be referred to as Intervention(s). -A section titled, "Re-Creation of Last 3 Hours Before Fall." This section contained pre-printed instructions for staff, "Below, the primary Nursing Assistant who observed and/or assisted the resident during the three hours prior to the fall will write a description to re-create the life of the resident before the fall:" This section also included an area for staff to enter their name. This section will be referred to as Re-Creation. Review of the facility's I&A reports revealed from 5/8/13 through 10/14/13 Resident #1 sustained 6 falls while in her room. *5/8/13 at 8:05 a.m., found sitting on floor beside her bed. --Follow-Up: changed type mattress due to surface being slick --Intervention(s): Nonskid footwear placed on both feet, remind to use call light, mattress changed --Re-Creation: "Took the residents {sic} breakfast tray in, she was still kind of asleep in bed and told me she was slowly waking up." This handwritten entry was signed by a CNA. Note: The Re-Creation section did not include the last 3 hours before the fall, from 5:05 a.m. to 8:05 a.m. *7/19/13 at 8:00 p.m., found on floor, tried to ambulate to bathroom (BR), lost balance and fell , was using a cane. A different section in the report documented, unknown what the resident was doing during or just prior to fall. --Follow-Up: Has safe, new Front Wheeled Walker in place at this time. --Intervention(s): Bed in lowest position, non-skid footwear, frequent checks, and alert charting Note: The Report documented frequent checks however the Fall CP did not include frequent checks as an approach or any type of supervision as an approach. --Re-Creation: "Resident had reported hard lump along lt (left) jawline that was painful, eat dinner in room, rested." This handwritten entry was signed by a RN. Note: The ReCreation section did not include the last 3 hours before the fall from 5:00 p.m. to 8:00 p.m. The resident was sent to a local hospital emergency room for left jaw and neck evaluation. It was determined the resident's parotid gland was infected, the MD ordered, and the resident received antibiotic therapy. *7/23/13 at 8:20 a.m., found on back in BR, lost balance and fell . --Follow-up: care planned to have audible alarms at all times --Intervention(s): Nonskid footwear, bed at appropriate height, audible alarms at all times, and transfers with assist of one person --Re-Creation: "5:30 am assisted rsdt (resident) to bathroom, returned to bed was sleeping at 6 am (6:00 am) report given to next shift CNAs." This handwritten entry was signed by a CNA. Note: The Re-Creation section did not include the last 3 hours before the fall. The nightshift CNA provided information however the report did not contain information from the next shift (dayshift) CNAs, from 6:00 a.m. to 8:20 a.m. *8/21/13 at 12:35 p.m., attempted to self transfer from wheelchair (wc) to bed, found sitting on the floor in front of wc. --Follow-up: audible alarms in place, frequent checks, reminded to use call light and wait for assistance. Rsdt demonstrated appropriate use of call light and verbalized will call for assistance. --Intervention(s): Remind to use call light --Re-Creation: "Rsdt had just eaten lunch & was toileted at 1200 noon." This handwritten entry was not signed. Note: The Re-Creation section did not include the last 3 hours before the fall from 9:35 a.m. to 12:00 p.m. *9/21/13 at 11:00 p.m., found sitting on floor at the foot of bed, Rsdt complained of left hip pain, not wearing proper footwear, audible alarms sounding --Follow-up: Chemistry strip within normal limits, alarms in place, nonskid footwear in place, ensure 4 p's (frequent toileting, positioning, pain assessment and placement of equipment) --Intervention: Remind to use call light and wait for assist, alarm in use and working, nonskid footwear, use of assistive device walker, wheelchair, SBA (standby assist), bed at correct height --ReCreation: "Resident was in bed at 10:00 pm with alarm on. Checked at 10:50 pm, still in bed with alarm on. Resident got up at 11:00 pm and was found sitting on floor next to bed A. Alarm was on." This handwritten entry was signed by a CNA. Note: The Re-Creation section did not include the last 3 hours before the fall. A CNA provided information from 10:00 to 11:00 a.m. however the report did not contain information from 8:00 a.m. to 10:00 a.m. --The resident's 9/21/13 Pain Assessment contained a handwritten entry on the back of the form, "9/21/13 sent to (name of hospital) ER for Eval & tx (emergency room for evaluation and treatment)." The 9/22/12 local hospital x-ray findings were no fracture or other significant osseous (of, relating to, or composed of bone) abnormality. *10/14/13 at 1:15 p.m., found on floor next to bed, Rsdt sent to local hospital for evaluation. Rsdt positive for UTI - started antibiotic therapy. A section titled, What appears to be the root cause of the fall, contained a handwritten entry, "Rsdt self transferred & her pull tab alarm was not attached to her. (she removes it)." --Follow-up: audible alarms to wheelchair discontinued, Rsdt moved to (room number) closer to nurses station and bathroom motion alarm to bathroom. Rsdt continued with antibiotic related to UTI, to end 10/22/13. --Intervention: change alarm to pressure pad, move Rsdt closer to nursing station --Re-Creation: "Rsdt has urgency & (and) had been up & down to the bathroom which is normal for her." This handwritten entry was signed by a LPN. Note: The Re-Creation section did not include the last 3 hours before the fall from 10:15 a.m. to 1:15 p.m. Note: The resident's chart contained a 10/14/13 local hospital radiology report which documented, Dizziness with fall. One of the findings was, Probably 5 mm (millimeter) chronic subdural hematoma along the left cerebral convexity. One of the Impressions was, no acute intracranial abnormality. On 10/24/13 at 11:20 a.m., the surveyor and RN #9 discussed Resident #1's I&A reports. The resident sustained [REDACTED]. The RN stated, "We added interventions after each fall and added the 4 p's (frequent toileting, positioning, pain assessment and placement of equipment) on 9/21/13." Note: The resident's Fall CP did not include frequent toileting or positioning. The Bowel and Bladder (B&B) CP contained an approach, Rsdt required every 2-3 hour prompted toileting and prn resident request in attempt to decrease urinary incontinence. The B&B CP did not include frequent toileting. On 10/25/13 at 9:30 a.m., the Administrator and the DON were informed of the concern. On 10/28/13 at 1:37 p.m., the facility faxed additional information related to Resident #1's 10/14/13 fall. However, the faxed information did not resolve the concern of the resident sustaining 6 falls from 5/8/13 to 10/14/13 and the I&A reports did not provide comprehensive information to make appropriate interventions or determinations.